With severe pneumonia, the patient needs a higher level of care than general medical-surgical. Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. Assess for mental status changes. Nursing Diagnosis: Impaired Gas Exchange related to decreased lung compliance and altered level of consciousness as evidence by dyspnea on exertion, decreased oxygen content, decreased oxygen saturation, and increased PCO2. Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. It involves the inflammation of the air sacs called alveoli. a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. As such, here are the signs and symptoms that demonstrate the presence of impaired gas exchange. - A nurse should be aware of some of the common side effects of antitubercular drugs like rifampin, one of which is orange discoloration of body fluids such as urine, sweat, tears, and sputum. a. NMNEC Concept: Gas Exchange. 7. Provide tracheostomy care. 4) Recent abdominal surgery. f. PEFR As an Amazon Associate I earn from qualifying purchases. It is important to acknowledge their limited information about the disease process and start educating him/her from there. Assessment findings include a new onset of confusion, a respiratory rate of 42 breaths/minute, a blood urea nitrogen (BUN) of 24 mg/dL, and a BP of 80/50 mm Hg. Saline instillation can cause bacteria to shift to the lower lung areas, increasing the risk of inflammation and invasion of sterile tissues. The patient will have a big chance to remember how to administer or perform any therapeutic regimen if they are given the chance to demonstrate and have him/her verbalize their understanding about it. Decreased skin turgor and dry mucous membranes as a result of dehydration. Air trapping c. a throat culture or rapid strep antigen test. However, here are some potential NANDA nursing diagnoses that may be applicable: Impaired gas exchange related to decreased lung expansion and ventilation-perfusion imbalance; . The patient will most likely feel comfortable and easy to breathe when their head is elevated in bed. a. Assess the patient for iodine allergy. Consider sources of infection.Any inserted lines such as IVs, urinary catheters, feedings tubes, suction tubing, or ventilation tubes are potential sources of infection. Increasing the intake of foods that are high in vitamin C does not decrease exposure to others. Apply pressure to the puncture site for 2 full minutes. a. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. A tracheostomy is safer to perform in an emergency. c. There is equal but diminished movement of the 2 sides of the chest. 8. To care for the tracheostomy appropriately, what should the nurse do? How to use esophageal speech to communicate What is the first patient assessment the nurse should make? Nurses also play a role in preventing pneumonia through education. Decreased compliance contributes to barrel chest appearance. Nursing Diagnosis: Ineffective Breathing Pattern related to decreased lung expansion secondary to pneumonia as evidenced by a respiratory rate of 22, usage of accessory muscles, and labored breathing. This intervention decreases pain during coughing, thereby promoting a more effective cough. - Pertussis is a highly contagious infection of the respiratory tract caused by the gram-negative bacillus Bordetella pertussis. Always wear gloves on both hands for suctioning. Which immediate action does the nurse take? No interventions are necessary for these findings. Reporting complications of hyperinflation therapy to the health care provider. c. a throat culture or rapid strep antigen test. After which diagnostic study should the nurse observe the patient for symptoms of a pneumothorax? The injected inactivated influenza vaccine is recommended for individuals 6 months of age and older and those at increased risk for influenza-related complications, such as people with chronic medical conditions or those who are immunocompromised, residents of long-term care facilities, health care workers, and providers of care to at-risk persons. Nutrition reviews, 68(8), 439458. Decreased immunoglobulin A (IgA) decreases the resistance to infection. "You should get the inactivated influenza vaccine that is injected every year." Here are 11 nursing diagnoses common to pneumonia nursing care plans (NCP). d. Bradycardia Decreased functional cilia and decreased force of cough from declining muscle strength cause decreased secretion clearance. What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? Desired Outcome: Within 1 hour of nursing interventions, the patient will have oxygen saturation of greater than 90%. c. Explain the test before the patient signs the informed consent form. CH. Bacterial Pneumonia. If the probe is intact at the site and perfusion is adequate, an ABG analysis will be ordered by the HCP to verify accuracy, and oxygen may be administered, depending on the patient's condition and the assessment of respiratory and cardiac status. To help alleviate cough and allow the patient to rest, cough suppressants may be given at low doses. 4. A) Purulent sputum that has a foul odor d. Positron emission tomography (PET) scan. Early small airway closure contributes to decreased PaO2. This is most common in intensive care units usually resulting from intubation and ventilation support. Summarize why people were unsuccessful over 1,000 years ago when they tried to transform lead into gold. d. Apply an ice pack to the back of the neck. 's nose for several days after the trauma? a. a. Vt k. Value-belief: Noncompliance with treatment plan, conflict with values, The abnormal assessment findings of dullness and hyperresonance are found with which assessment technique? 1) b. a. d. Pleural friction rub c. TLC: (2) Maximum amount of air lungs can contain The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. 1) SpO2 of 85% 2) PaCO2 of 65 mm Hg 3) Thick yellow mucus expectorant 4) Respiratory rate of 24 breaths/minute 5) Dullness to percussion over the affected area Click the card to flip a. Finger clubbing Initially, oxygen is administered at low concentrations, and oxygen saturation is closely monitored. b. Palpation Impaired Gas Exchange Nursing Diagnosis & Care Plan Related Factors Physiological damage to the alveoli Circulatory compromise Lack of oxygen supply Insufficient availability of blood (carrier of oxygen) Subjective Data: patient's feelings, perceptions, and concerns. 3. Position the patient to be comfortable (usually in the half-Fowler position). Document the results in the patient's record. Has been NPO since midnight in preparation for surgery Decreased force of cough Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Normally the AP diameter should be 13 to 12 the side-to-side diameter. 3) g. Position the patient sitting upright with the elbows on an over-the-bed table. b. e. Rapid respiratory rate. Assist the patient when they are doing their activities of daily living. d. a total laryngectomy to prevent development of second primary cancers. Use a sterile catheter for each suctioning procedure. Lower Respiratory Tract Infections and Disord, Lewis Ch. d. Oxygen saturation by pulse oximetry j. Coping-stress tolerance 25: Assessment: Respiratory System / CH. Teach the importance of complying with the prescribed treatment and medication. b. The nurse can also teach coughing and deep breathing exercises. Antibiotics. She earned her BSN at Western Governors University. Always change the suction system between patients. f. Cognitive-perceptual: Decreased cognitive function with restlessness, irritability. Medications such as paracetamol, ibuprofen, and. At the end of the span of care, the patient will be able to have an effective, regular, and improved respiratory pattern within a normal range (12-20 cycles per minute). Although inadequately treated -hemolytic streptococcal infections may lead to rheumatic heart disease or glomerulonephritis, antibiotic treatment is not recommended until strep infections are definitely diagnosed with culture or antigen tests. 1) The cough may last from 6 to 10 weeks. d. Small airway closure earlier in expiration Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. 2. 3. Surgical incisions and any skin breakdown should be monitored for redness, warmth, drainage, or odor that signals an infection. Allow patients to ask a question or clarify regarding their treatment. Nuclear scans use radioactive materials for diagnosis, but the amounts are very small and no radiation precautions are indicated for the patient. An open reduction and internal fixation of the tibia were performed the day of the trauma. Study Resources . Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. Attend to the patients queries regarding their pneumonia treatment. Teach patients some signs and symptoms that prompt immediate medical attention such as dyspnea. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Finger clubbing and accessory muscle use are identified with inspection. d. A tracheostomy tube and mechanical ventilation, What should the nurse include in discharge teaching for the patient with a total laryngectomy? b. b. treatment with antifungal agents. Ensure that the patient performs deep breathing with coughing exercises at least every 2 hours. Place or install an air filter in the room to prevent the accumulation of dust inside. Educating him/her to use the incentive spirometer will encourage him/her to exercise deep inspiration that will help get more oxygen in the lungs and prevent hypoxia. Expresses concern about his facial appearance c. Decreased chest wall compliance c. It has two tubings with one opening just above the cuff. The most important factor in managing allergic rhinitis is identification and avoidance of triggers of the allergic reactions. Why does a patient's respiratory rate increase when there is an excess of carbon dioxide in the blood? 's airway before and after surgery? Changes in behavior and mental status can be early signs of impaired gas exchange. nursing care plan for pneumonia nursing care plan for stroke nursing care . A) Sit the patient up in bed as tolerated and apply Fill fluid containers immediately before use (not well in advance). Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Help the patient get into a comfortable position, usually the half-Fowler position. Pneumonia: Bacterial or viral infections in the lungs . What do these findings indicate? It must include the local 911 numbers, hospitals, and immediate keen of the patient. COPD ND3: Impaired gas exchange. Advise individuals who smoke to stop smoking, especially during the preoperative and postoperative periods. The treatment and medication should be prescribed by the attending physician and do not take meds that are not prescribed to prevent unnecessary drug interaction. If the patient is ambulatory, walking should be encouraged within the patients tolerance. a. Observing for hypoxia is done to keep the HCP informed. 1# Priority Nursing Diagnosis. For best yield, blood cultures should be obtained before antibiotics are administered. Etiology The most common cause for this condition is poor oxygen levels. c) 5. Viral pneumonia. Encourage rest and limit exertion.Patients may not be able to tolerate too much activity. Nursing care plans: Diagnoses, interventions, & outcomes. Poor peripheral perfusion that occurs with hypovolemia or other conditions that cause peripheral vasoconstriction will cause inaccurate pulse oximetry, and ABGs may have to be used to monitor oxygenation status and ventilation status in these patients. An SpO2 of 88% and a PaO2 of 55 mm Hg indicate inadequate oxygenation and are the criteria for continuous oxygen therapy (see Table 25.10). b. e. FVC: (5) Amount of air that can be quickly and forcefully exhaled after maximum inspiration c. Check the position of the probe on the finger or earlobe. d. Contain dead air that is not available for gas exchange. d. Patient can speak with an attached air source with the cuff inflated. d. Oxygen saturation by pulse oximetry. Amount of air that can be quickly and forcefully exhaled after maximum inspiration A prominent protrusion of the sternum is the pectus carinatum and diminished movement of both sides of the chest indicates decreased chest excursion. Discuss to him/her the different pros and cons of complying with the treatment regimen. Steroids: To reduce the inflammation in the lungs. General physical assessment findingsof pneumonia. Administer antibiotics.A diagnosis of pneumonia will warrant antibiotic treatment. d. Place 1 hand on the lower anterior chest and 1 hand on the upper abdomen. The bacteria may enter the blood stream and cause, Trouble sleeping. Advised the patient to dispose of and let out the secretions. Streptococcus pneumoniae is the causative agent for most of the cases of adult community-acquired pneumonia. Impaired gas exchange occurs due to alveolar-capillary membrane changes, such as fluid shifts and fluid collection into interstitial space and alveoli. Pulmonary activities that help prevent infection/pneumonia include deep breathing, coughing, turning in bed, splinting wounds before breathing exercises, walking, maintaining adequate oral fluid intake, and using a hyperinflation device. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. Impaired Gas Exchange; May be related to. A knowledgeable patient is more likely to comply with therapy. If he or she cannot do it alone, make sure to place suction secretions at the bedside to use anytime. Dont forget to include some emergency contact numbers just in case there is an emergency. Bronchodilators: To dilate or relax the muscles on the airways. Desired Outcome: At the end of the span of care, the patient will manifest better lung ventilation and improve tissue perfusion, and maximum optimal gas exchange by having normal arterial blood gas results, minimum to no symptoms of respiratory distress, and normal production of mucus in the airway. a. Proper nutrition promotes energy and supports the immune system. Tuberculosis frequently presents with a dry cough. Cough reflex 2/21/2019 Compiled by C Settley 10. Please read our disclaimer. 3. To help clear thick phlegm that the patient is unable to expectorate. Impaired gas improved or presence of retained secretions client: exchange ventilation and adventitious sound -Demonstrated adequate improved wheezes oxygenation of -Decrease of ventilation and tissues by ABG of: -Palpate for fremitus vibratory tremors adequate pH:7.35-7.45 suggest fluid oxygenation of Nursing diagnosis Related factors Defining characteristics Examples of this type of nursing diagnosis include: Decreased cardiac output Chronic functional constipation Impaired gas exchange Problem-focused nursing diagnoses are typically based on signs and symptoms present in the patient. Pneumonia is an infection of the lungs caused by a bacteria or virus. Assess the need for hyperinflation therapy. During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? A) Pneumonia c. Place the thumbs at the midline of the lower chest. Administer oxygen with hydration as prescribed. Assess lab values.An elevated white blood count is indicative of infection. 26: Upper Respiratory Problems / CH. The arterial oxygen saturation by pulse oximetry (SpO2) compared with normal values will not be helpful in this older patient or in a patient with respiratory disease as the patient's expected normal will not be the same as standard normal values. c. Patient in hypovolemic shock - The patient's clinical picture is most likely pulmonary embolism (PE), and the first action the nurse should take is to assist with the patient's respirations. A) Admit the patient to the intensive care unit. Assess the patients vital signs at least every 4 hours. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). On inspection, the throat is reddened and edematous with patchy yellow exudates. Techniques that will be used to alleviate a dry mouth and prevent stomatitis Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. Patients who are weak or fatigued with an ineffective cough can be taught how to suction themselves. If there is no improvement with the symptoms, the doctor may prescribe a different type of antibiotic. The patient must have enough rest so that the body will not be exhausted and avoid an increase in the oxygen demand. 3. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. The nurse anticipates that interprofessional management will include c. A tracheostomy tube allows for more comfort and mobility. This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. Weigh patient daily at same time of day and on same scale; record weight. d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration Maegan Wagner is a registered nurse with over 10 years of healthcare experience. Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas. HR 68 bpm d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. Discharge from the hospital is expected if the patient has at least five of the following indicators: temperature 37.7C or less, heart rate 100 beats/minute or less, heart rate 24 breaths/minute or less, systolic blood pressure (SBP) 90 mm Hg or more, oxygen saturation greater than 92%, and ability to maintain oral intake. To regulate the temperature of the environment and make it more comfortable for the patient. Since the patient is manifesting impaired gas exchange, one of the good indications that the oxygen absorption inside the body is not improving is through the skin changes, nail bed discoloration, and mucous production. A significant increase in oxygen demand to maintain O2 saturation greater than 92% should be reported immediately. e. Observe for signs of hypoxia during the procedure. Fever reducers and pain relievers. c. Tracheal deviation Usually, people with pneumonia preferred their heads elevated with a pillow. d. Comparison of patient's current vital signs with normal vital signs. Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor in increasing the likelihood of pneumonia. See Table 25.8 for more thorough descriptions of these sounds and their possible etiologies and significance. Remove the inner cannula and replace it per institutional guidelines. Use only sterile fluids and dispense with sterile technique. This position provides comfort, promotes descent of the diaphragm, maximizes inspiration, and decreases work of breathing. A) "I will need to have a follow-up chest x-ray in six to. Promote fluid intake (at least 2.5 L/day in unrestricted patients). Allow the patient to have enough bed rest and avoid strenuous activities. a. The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. b. Wear gloves on both hands when handling the cannula or when handling ventilation tubing. 3.5 Acute Pain. a. Stridor This can occur for various reasons, including but not limited to: lung disease, heart failure, and pneumonia. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. The tissue changes of TB and cancer of the lung may be diagnosed by chest x-ray or CT scan, MRI, or positron emission tomography (PET) scans. 8 . Arterial blood gas (ABG) values: May vary depending on extent of pulmonary involvement or other coexisting conditions. Nursing Care Plan 2 St. Louis, MO: Elsevier. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. 2) It is a highly contagious respiratory tract infection. deep inspiratory crackles (rales) caused by respiratory secretions, and circumoral cyanosis (a late finding). a. Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively. Provide tracheostomy care. associated with increased fluid loss in the presence of tachypnea, fever, or diaphoresis Desired outcome: at least 24 hours before hospital discharge, the patient is normovolemic, i.e., has a urine output of 30 mL/h or greater, stable weight, heart rate less than 100 bpm, blood pressure greater than 90 mm Hg, fluid intake equal to fluid excretion, moist mucous membranes, and normal skin turgor. Week 1 - Nursing Care of Patients with Respiratory Problems Influenza, Atelectasis, Pneumonia, TB, & Expert Help. Change the tube every 3 days. Keep the head end of the bed at a height of 30 to 45 degrees and turn the patient to the lateral position. How does the nurse respond? a. c. Mucociliary clearance 3) Illicit drug intake The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. 27 - Lower Respiratory Problems, Coronary Artery Disease & Acute Coronary Synd, Integumentary System (Lewis Med-Surg CH.22 &, Barbara T Nagle, Hannah Ariel, Henry Hitner, Michele B. Kaufman, Yael Peimani-Lalehzarzadeh, 1.1 (Anatomy) Functional Organization of the. Alveolar sacs are terminal structures of the respiratory tract, where gas exchange takes place. The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? The alcohol intake of the patient is within normal limits, so it is not correct to say that alcohol may have damaged the liver. So to avoid that, they must be assisted in any activities to help conserve their energy. Blood tests elevated white blood cell count may be a sign of an ongoing infection, Sputum culture to determine the causative agent, Imaging chest X-ray to determine active infection and its severity; bronchoscopy to check any blockage of the airways; CT scan for a more detailed lung imaging, Arterial blood gas (ABG) test using an arterial blood sample to measure the oxygen level, Pleural fluid culture taking a pleural fluid sample by inserting a needle between the pleural cavity and the ribs in order to determine the causative agent. 2. Hyperkalemia is not occurring and will not directly affect oxygenation initially. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue). Activity intolerance 2. Objective Data: >Tachypnea RR: 33 breaths per min >Dyspnea >Peripehral Cyanosis Rationale An infection triggers alveolar inflammation and edema. Encouraging oral fluids will mobilize respiratory secretions. Decreased force of cough b. Finger clubbing Buy on Amazon. 2. of . 6) Minimize time on public transportation. d. Activity-exercise: Decreased exercise or activity tolerance, dyspnea on rest or exertion, sedentary habits a. Assess the patient for iodine allergy. It is important to assess the ability of the patient to do self-care ost especially if he or she is having respiratory symptoms. Impaired gas exchange is a condition that occurs when there is an insufficient amount of oxygen in the blood. Allow 90 minutes for. Interstitial edema b. Unstable hemodynamics Nursing Diagnosis. Nursing Diagnosis: Impaired Gas Exchange related to the overproduction of mucus in the airway passage secondary to pneumonia as evidenced by cyanosis, restlessness, and irritability. Anatomy of the Respiratory System The respiratory system is composed of the nose, pharynx, larynx, trachea, bronchi, and lungs. Antiviral agents will help reduce the duration and severity of influenza in those at high risk, but immunization is the best control. Impaired cardiac output e. Sleep-rest St. Louis, MO: Elsevier. The patient will also be able to fully understand how pneumonia is being transmitted to avoid having the disease transfer from other family members. Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. d. Use over-the-counter antihistamines and decongestants during an acute attack. Implement precautions to prevent infection.Proper handwashing is the best way to prevent and control the spread of infection. They are as follows: Ineffective Airway Clearance Impaired Gas Exchange Ineffective Breathing Pattern Risk for Infection Acute Pain Decreased Activity Tolerance Hyperthermia Risk for Deficient Fluid Volume Risk for Imbalanced Nutrition: Less Than Body Requirements 1. e. Suction the tracheostomy tube when there is a moist cough or a decreased arterial oxygen saturation by pulse oximetry (SpO2). a. b. The nurse is providing postoperative care for a patient three days after a total knee arthroplasty. Obtain a sputum sample for culture.If the patient can cough, have them expectorate sputum for testing. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before eliciting additional help. Page . Normal findings in arterial blood gases (ABGs) in the older adult include a small decrease in PaO2 and arterial oxygen saturation (SaO2) but normal pH and PaCO2. Are there any collaborative problems? g. Position the patient sitting upright with the elbows on an over-the-bed table. Pneumonia. b. Expected outcomes a. 28: Obstructive Pulmonary Diseases. This can lead to hypoxia (lack of oxygen), and possibly tissue damage. Retrieved February 9, 2022, from. Give health teachings about the importance of taking prescribed medication on time and with the right dose. After the posterior nasopharynx is packed, some patients, especially older adults, experience a decrease in PaO2 and an increase in PaCO2 because of impaired respiration, and the nurse should monitor the patient's respiratory rate and rhythm and SpO2. c. Airway obstruction There is an induration of only 5 mm at the injection site. associated with inadequate primary defenses (e.g., decreased ciliary activity), invasive procedures (e.g., intubation), and/or chronic disease Desired outcome: patient is free of infection as evidenced by normothermia, a leukocyte count of 12,000/mm3 or less, and clear to whitish sputum. Number the following actions in the order the nurse should complete them. This patient is older and short of breath. a. Trachea Related to: As evidenced by: obstruction of airways, bronchospasm, air trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to move secretions, hypoventilation . Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. e. Teach the patient about home tracheostomy care. oxygen. e. Decreased functional immunoglobulin A (IgA). Primary care, with acute or intensive care hospitalization due to complications. Always maintain sterility or aseptic techniques when performing any invasive procedure. Chronic hypoxemia 1. Lack of lung expansion caused by kyphosis of the spine results in shallow breathing with decreased chest expansion. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Normal venous blood gas values reflect the normal uptake of oxygen from arterial blood and the release of carbon dioxide from cells into the blood, resulting in a much lower PaO2 and an increased PaCO2. I do not know if it's just overthinking it or what but all the care plans i have read . If a patient is immobile they must be repositioned every 2 hours to maintain skin integrity. Related to: As evidenced by: Corticosteroids and bronchodilators are not useful in reducing symptoms. Organizing the tasks will provide a sufficient rest period for the patient. Report significant findings. Impaired gas exchange diagnosis was present in 42.6% of the children in the first assessment. c. Terminal structures of the respiratory tract b. Nutritional-metabolic b. Nutritional-metabolic: Decreased fluid intake, anorexia and rapid weight loss, obesity d. Pleural friction rub. Nursing Diagnosis: Hyperthermia related to the disease process of bacterial pneumonia as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, and profuse sweating. The nurse selects Ineffective Breathing Pattern after validating this patient is demonstrating the associated signs and symptoms related to this nursing diagnosis: Dyspnea Increase in anterior-posterior chest diameter (e.g., barrel chest) Nasal flaring Orthopnea Prolonged expiration phase Pursed-lip breathing Tachypnea Consider imperceptible losses if the patient is diaphoretic and tachypneic. A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. The nurse provides care for a patient with a suspected lung abscess and expects which assessment finding? The live attenuated influenza vaccine is given intranasally and is recommended for all healthy people between the ages of 2 and 49 years but not for those at increased risk of complications or HCPs. c. Send labeled specimen containers to the laboratory. If they cannot, sputum can be obtained via suctioning. This can be due to a compromised respiratory system or due to lung disease.